=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063467595
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB BENFORD MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2006
-----------------------------------------------------
Last Update Date | 10/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 NORTH JACKSON AVENUE
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-923-7121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2100 POWELL STREET SUITE 900
-----------------------------------------------------
City | EMERYVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94608-1804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-350-2664
-----------------------------------------------------
Fax | 510-879-4076
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | MD195812
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | A60475
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------